Note Bloat Disrupts Utility of Electronic Health Records

Marcia Frellick

March 16, 2016

SAN DIEGO — Conveniences built into electronic health records can present problems for healthcare providers, such as note bloat, alert fatigue, and disagreements about what to post on patient portals, experts said here at the Society of Hospital Medicine 2016 Annual Meeting.

In the days of paper records, "I never handwrote an entire CAT scan report in my notes," said Julie Hollberg, MD, chief medical informatics officer for Emory Healthcare in Atlanta. "Why do we do that now?"

Note bloat, enabled by the copy-and-paste function, can increase the time that other members of the care team have to spend on a record, she explained. It also begs the question of whether a physician is thoughtfully analyzing the plan for the patient.

Physicians have 100% control over what goes in the notes, Dr Hollberg emphasized. "The technology doesn't make us do anything."

Less clear is the line between efficiency and note quality.

"This requires a cultural change in our thinking with respect to what clinical documentation is for," said Brian Clay, MD, interim chief medical informatics officer at the University of California, San Diego Health System. "And we all need to be more comfortable with referring to information elsewhere in the health record system, rather than replicating it in the note itself."

He said he sees electronic health records moving toward increased transparency so that readers can see what part of a note was copied and who wrote it originally.

"Hopefully, this will provide a needed incentive to reduce inappropriate copying and pasting," he told Medscape Medical News.

Dr Hollberg asked the audience to vote on whether copy and paste is a useful tool. Nearly all hands went up. Then she asked whether people think it has decreased the quality of documentation. Almost as many hands went up.

"We're all in that conundrum until electronic health records get better; we're not necessarily ready to give it up," she said.

Alerts Often Ignored

Electronic alerts, mandated by meaningful-use guidelines, have saved physicians time and added medical decision support with pop-up warnings on drug–drug interactions and allergy information.

Although Dr Hollberg said she fundamentally believes in the alerts, she pointed out that they are being overridden at rates above 90%.

"When these interactions pop up, you don't know if you're at risk of killing someone or causing a rash. That's where we need to work with our vendors to create better end-user interfaces," she explained.

Dr Clay pointed out that if physicians see alerts that are not providing clear value, alert fatigue will set in and physicians will get jaded.

"We have built very few interruptive alerts into our electronic medical record," he said. "The total of such alerts that display to physicians numbers in the single digits."

However, all electronic health records systems have an overabundance of alerts for drug–drug interactions that pop up when medication orders are being signed. "These alerts are part of the medication database that each healthcare organization purchases from a third-party vendor, and they are far and away the majority of pop-up alerts that physicians see," Dr Clay noted.

Scope of the Patient Portal Controversial

Patients have the right to get their medical information at any time, but physicians differ on how much patients should be able to see in the patient portal without first talking with a physician.

Institutions are starting to release laboratory results, but radiology reports are not always available in the patient portal because of concerns about how patients could interpret results, such as a nodule, without a physician's explanation.

There are real benefits to patients getting results in real time, said Dr Hollberg. "Right now, we release radiology 7 days after it's done. We're working on pushing that back to 3 days on both the inpatient and outpatient side."

The fear that the release of information would lead to confusion and anxiety in patients and require that doctors spend more time answering questions has not materialized, she told Medscape Medical News.

In a recent study, researchers evaluated an app that allowed patients who viewed their medical records, or a family member, to text the doctor or nurse with questions (J Am Med Inform Assoc. 2016;23:80-87). Patients sent an average of only 1.8 messages each during the course of their hospitalization, she reported.

"Absolutely there needs to be improvements in the technology," Dr Hollberg said. "But I want to encourage us as a group of strong clinicians to not wait until the vendors and the administration can work it out." She encouraged physicians to think proactively and join committees that will determine portal usage.

Dr Clay explained that patients at his institution have access to most information as quickly as possible through the portal. However, HIV, sexually transmitted infection, and biopsy results are disclosed only during a discussion with the physician.

Dr Hollberg and Dr Clay have disclosed no relevant financial relationships.

Society of Hospital Medicine 2016 Annual Meeting. Presented March 8, 2016.


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